Impact of a 'diagonal' intervention on uptake of sexual and reproductive health services by female sex workers in Mozambique : a mixed-methods implementation study

CITATION: Lafort, Y. 2018. Impact of a diagonal intervention on uptake of sexual and reproductive health services by female sex workers in Mozambique : a mixed-methods implementation study. Frontiers in Public Health, 6:109, doi:10.3389/fpubh.2018.00109.The original publication is available at https://www.frontiersin.orgBackground: Female sex workers (FSWs) have high risks for adverse sexual and reproductive health (SRH) outcomes, yet low access to services. Within an implementation research project enhancing uptake of SRH services by FSWs, we piloted a “diagonal” intervention, which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal), and tested its effect. Methods: The study applied a convergent parallel mixed-methods design to assess changes in access to SRH services. Results of structured interviews with FSWs pre-intervention (N = 311) and thereafter (N = 404) were compared with the findings of eight post-intervention focus group discussions (FGDs) with FSWs and two with FSW-peer educators (PEs). Results: Marked and statistically significant rises occurred in consistent condom use with all partners (55.3–67.7%), ever use of female condoms (37.9–54.5%), being tested for HIV in the past 6 months (56.0–76.6%), using contraception (84.5–95.4%), ever screened for cervical cancer (0.0–16.9%) and having ≥10 contacts with a PE in the past year (0.5–24.45%). Increases mostly resulted from FSW-targeted outreach, with no rise detected in utilization of public health facilities. FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted. Conclusion: The combination of expanding FSW-targeted SRH services with improving access to the public health services resulted in an overall increased uptake of services, but almost exclusively because of the strengthened targeted (vertical) outreach services. Utilization of public SRH services had not yet increased and many barriers to access remained. Our diagonal approach was thus only successful in its vertical component. Improving access to the general health services remains nevertheless important and further research is needed how to reduce barriers. Ideally, the combination approach should be maintained and more successful approaches to increase utilization of public services should be explored.https://www.frontiersin.org/articles/10.3389/fpubh.2018.00109/fullPublisher's versio

Feasibility, acceptability and potential sustainability of a 'diagonal' approach to health services for female sex workers in Mozambique

Background: Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a 'diagonal' intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. Methods: Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions' feasibility, acceptability by providers, managers and policy makers, and potential sustainability. Results: The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. Conclusions: In the current Mozambican context, a 'diagonal' approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component

Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique

BACKGROUND: To improve retention in antiretroviral therapy (ART), lessons learned from chronic disease care were applied to HIV care, providing more responsibilities to patients in the care of their chronic disease. In Tete - Mozambique, patients stable on ART participate in the ART provision and peer support through Community ART Groups (CAG). This article analyses the evolution of the CAG-model during its implementation process. METHODS: A mixed method approach was used, triangulating qualitative and quantitative findings. The qualitative data were collected through semi-structured focus groups discussions and in-depth interviews. An inductive qualitative content analysis was applied to condense and categorise the data in broader themes. Health outcomes, patients’ and groups’ characteristics were calculated using routine collected data. We applied an ‘input – process – output’ pathway to compare the initial planned activities with the current findings. RESULTS: Input wise, the counsellors were considered key to form and monitor the groups. In the process, the main modifications found were the progressive adaptations of the daily CAG functioning and the eligibility criteria according to the patients’ needs. Beside the anticipated outputs, i.e. cost and time saving benefits and improved treatment outcomes, the model offered a mutual adherence support and protective environment to the members. The active patient involvement in several health activities in the clinics and the community resulted in a better HIV awareness, decreased stigma, improved health seeking behaviour and better quality of care. CONCLUSIONS: Over the past four years, the modifications in the CAG-model contributed to a patient empowerment and better treatment outcomes. One of the main outstanding questions is how this model will evolve in the future. Close monitoring is essential to ensure quality of care and to maintain the core objective of the CAG-model ‘facilitating access to ART care’ in a cost and time saving manner

Barriers to HIV and sexual and reproductive health care for female sex workers in Tete, Mozambique : results from a cross-sectional survey and focus group discussions

Background: In the context of an operational research project in Tete, Mozambique, use of, and barriers to, HIV and sexual and reproductive health (HIV/SRH) commodities and services for female sex workers (FSWs) were assessed as part of a baseline situational analysis. Methods: In a cross-sectional survey 311 FSWs were recruited using respondent driven sampling and interviewed face-to-face, and three focus group discussions were held with respectively 6 full-time Mozambican, 7 occasional Mozambican and 9 full-time Zimbabwean FSWs, to investigate use of, and barriers to, HIV/SRH care. Results: The cross-sectional survey showed that 71 % of FSWs used non-barrier contraception, 78 % sought care for their last sexually transmitted infection episode, 51 % of HIV-negative FSWs was tested for HIV in the last 6 months, 83 % of HIV-positive FSWs were in HIV care, 55 % sought help at a health facility for their last unwanted pregnancy and 48 % after sexual assault, and none was ever screened for cervical cancer. Local public health facilities were by far the most common place where care was sought, followed by an NGO-operated clinic targeting FSWs, and places outside the Tete area. In the focus group discussions, FSWs expressed dissatisfaction with the public health services, as a result of being asked for bribes, being badly attended by some care providers, stigmatisation and breaches of confidentiality. The service most lacking was said to be termination of unwanted pregnancies. Conclusions: The use of most HIV and SRH services is insufficient in this FSW population. The public health sector is the main provider, but access is hampered by several barriers. The reach of a FSW-specific NGO clinic is limited. Access to, and use of, HIV and SRH services should be improved by reducing barriers at public health facilities, broadening the range of services and expanding the reach of the targeted NGO clinic

Impact of a “Diagonal” Intervention on Uptake of Sexual and Reproductive Health Services by Female Sex Workers in Mozambique: A Mixed-Methods Implementation Study

BackgroundFemale sex workers (FSWs) have high risks for adverse sexual and reproductive health (SRH) outcomes, yet low access to services. Within an implementation research project enhancing uptake of SRH services by FSWs, we piloted a “diagonal” intervention, which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal), and tested its effect.MethodsThe study applied a convergent parallel mixed-methods design to assess changes in access to SRH services. Results of structured interviews with FSWs pre-intervention (N = 311) and thereafter (N = 404) were compared with the findings of eight post-intervention focus group discussions (FGDs) with FSWs and two with FSW-peer educators (PEs).ResultsMarked and statistically significant rises occurred in consistent condom use with all partners (55.3–67.7%), ever use of female condoms (37.9–54.5%), being tested for HIV in the past 6 months (56.0–76.6%), using contraception (84.5–95.4%), ever screened for cervical cancer (0.0–16.9%) and having ≥10 contacts with a PE in the past year (0.5–24.45%). Increases mostly resulted from FSW-targeted outreach, with no rise detected in utilization of public health facilities. FGD participants reported that some facilities had become more FSW-friendly, but barriers such as stock-outs, being asked for bribes and disrespectful treatment persisted.ConclusionThe combination of expanding FSW-targeted SRH services with improving access to the public health services resulted in an overall increased uptake of services, but almost exclusively because of the strengthened targeted (vertical) outreach services. Utilization of public SRH services had not yet increased and many barriers to access remained. Our diagonal approach was thus only successful in its vertical component. Improving access to the general health services remains nevertheless important and further research is needed how to reduce barriers. Ideally, the combination approach should be maintained and more successful approaches to increase utilization of public services should be explored

Effect of a 'diagonal' intervention on uptake of HIV and reproductive health services by female sex workers in three sub-Saharan African cities

Objectives: To enhance uptake of sexual and reproductive health (SRH) services by female sex workers (FSWs), we conducted an implementation study in which we piloted and tested context-specific diagonal' interventions, combining vertical, targeted interventions with horizontally improved access to the general health services, in three cities in sub-Saharan Africa. Methods: We collected indicators of SRH service uptake through face-to-face interviews with approximately 400 FSWs, pre- and post-intervention, in Durban, South Africa; Tete, Mozambique; and Mombasa, Kenya, recruited by respondent-driven sampling. Changes in uptake were tested for their statistical significance using multivariate logistic regression models. Results: In all cities, overall uptake of services increased. Having used all services for contraception, STI care, HIV testing, HIV care, cervical cancer screening and sexual violence, if needed, increased from 12.5% to 41.5% in Durban, 25.0% to 40.1% in Tete and 44.9% to 69.1% in Mombasa. Across cities, the effect was greatest in having been tested for HIV in the past six months which increased from 40.9% to 83.2% in Durban, 56.0% to 76.6% in Tete and 70.9% to 87.6% in Mombasa. In Tete and Mombasa, rise in SRH service use was almost entirely due to a greater uptake of targeted services. Only in Durban was there additionally an increase in the utilisation of general health services. Conclusion: SRH service utilisation improved in the short-term in three different sub-Saharan African contexts, primarily through vertical, targeted components. The long-term effectiveness of diagonal approaches, in particular on the use of general, horizontal health services, needs further investigation

Where Do Female Sex Workers Seek HIV and Reproductive Health Care and What Motivates These Choices? A Survey in 4 Cities in India, Kenya, Mozambique and South Africa.

A baseline cross-sectional survey among female sex workers (FSWs) was conducted in four cities within the context of an implementation research project aiming to improve FSWs' access to HIV, and sexual and reproductive health (SRH) services. The survey measured where FSWs seek HIV/SRH care and what motivates their choice.Using respondent-driven sampling (RDS), FWSs were recruited in Durban, South Africa (n = 400), Tete, Mozambique (n = 308), Mombasa, Kenya (n = 400) and Mysore, India (n = 458) and interviewed. RDS-adjusted proportions were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests.Across cities, FSWs most commonly sought care for the majority of HIV/SRH services at public health facilities, most especially in Durban (ranging from 65% for condoms to 97% for HIV care). Services specifically targeting FSWs only had a high coverage in Mysore for STI care (89%) and HIV testing (79%). Private-for-profit clinics were important providers in Mombasa (ranging from 17% for STI care and HIV testing to 43% for HIV care), but not in the other cities. The most important reason for the choice of care provider in Durban and Mombasa was proximity, in Tete 'where they always go', and in Mysore cost of care. Where available, clinics specifically targeting FSWs were more often chosen because of shorter waiting times, perceived higher quality of care, more privacy and friendlier personnel.The place where care is sought for HIV/SRH services differs substantially between cities. Targeted services have limited coverage in the African cities compared to Mysore. Convenience appears more important for choosing the place of care than aspects of quality of care. The best model to improve access, linking targeted interventions with general health services, will need to be tailored to the specific context of each city

Sexual and reproductive health services utilization by female sex workers is contextspecific : results from a cross-sectional survey in India, Kenya, Mozambique and South Africa

CITATION: Lafort, Y., et al. 2017. Sexual and reproductive health services utilization by female sex workers is contextspecific : results from a cross-sectional survey in India, Kenya, Mozambique and South Africa. Reproductive Health, 14:13, doi:10.1186/s12978-017-0277-6.The original publication is available at https://reproductive-health-journal.biomedcentral.comBackground: Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities. Methods: A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 ‘seeds’ identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn–Šidák correction. Results: Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs’ sociodemographic characteristics. Conclusion: The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-017-0277-6Publisher's versio

Participants of the focus group discussions and in depth interviews.

<p>CAG – Community ART groups; IDI – In depth interviews; FGD – Focus group discussions.</p>§<p>Patients in CAG were divided in three groups according to their geographical residence and the distance to the clinics: (1) remote areas – patients who have to travel long distances to access care with major transport problems, (2) rural areas –patients who can reach healthcare services by foot or bicycle and (3) semi-urban areas – patients who live close to main road with access to public transport.</p><p><b>*</b> To ensure a fluent implementation of the CAG model and monitoring of the groups, MSF appointed counsellors to the large health facilities, taking a major role in the daily management of the CAG activities. Whereas in smaller health facilities, MoH nurses are responsible for all these activities. For the interviews nurses have been divided into two groups: (1) nurses working with counsellors and (2) nurses working without counsellors.</p